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CardiologyAdvisor.com 

The American Heart Association (AHA) released a scientific statement updating ambulatory blood pressure (BP) monitoring recommendations for children and adolescents. The statement was published in the journal Hypertension.

BP levels in adolescents are strongly related with hypertension in adulthood, atherosclerotic cardiovascular disease, and premature mortality.

The American Academy of Pediatrics recommended in 2017 for children suspected of hypertension to undergo ambulatory BP monitoring (ABPM). This statement from the AHA updates these recommendations using new data.

The revised classification scheme for clinic-assessed BP is as follows:

• Normal BP: less than 95th percentile at aged younger than 13 years and less than 130/80 mm Hg at aged 13 years or older
• White coat hypertension (WCH): 95th percentile or greater at aged younger than 13 years and 130/80 mm Hg or greater at aged 13 years or older
• Masked hypertension: less than 95th percentile at aged younger than 13 years and less than 130/80 mm Hg  at aged 13 years or older
• Ambulatory hypertension: 95th percentile or greater at aged younger than 13 years and 130/80 mm Hg or greater at aged 13 years or older

ABPM is recommended because it mitigates spurious BP deviations due to anxiety (ie, WCH) or deviations in circadian BP patterns. The AHA recommends for ABPM to be used to confirm a diagnosis of hypertension observed in the clinic. ABPM is also an appropriate tool to use to optimize therapy in chronic kidney disease, diabetes, obesity, and obstructive sleep apnea and to identify secondary causes of hypertension in patients with certain genetic syndromes.

The revised classification scheme for ABPM is as follows:

• Normal BP/WCH: less than 95th percentile  or adolescent cut points at aged younger than 13 years  and less than 125/75 mm Hg 24 hours and less than 130/80 mm Hg wake and less than 110/65 mm Hg sleep at aged 13 years or older
• Masked/ambulatory hypertension: 95th percentile or greater  or adolescent cut points at aged younger than 13 years and 125/75 mm Hg or greater 24 hours or 130/80 mm Hg or greater wake or 110/65 mm Hg or greater sleep at aged 13 years or older

If a patient presents as normative during both clinic and ABPM, the child likely does not have hypertension. If deviations are observed in one of the assessments, they likely have either WCH or masked hypertension.

The current monitoring period recommendation is for a 24-hour assessment.

No serious adverse events of ABPM have been reported in children, however, some data suggests ABPM can disturb sleep in some children. Comprehensive patient education may help to reduce ABPM failure rate.

For evaluating the pediatric population, several oscillometric and auscultatory BP monitors have been validated in children. Not all monitors, however, have been validated. Clinicians should consult the American Medical Association, British and Irish Hypertension Society, Hypertension Canada, and Stride BP websites to ensure their equipment has been validated for use in pediatrics.

To perform ABPM, nurses or other clinicians should follow standardized approaches to maintain equipment functionality.

The statement authors concluded that several gaps in knowledge about pediatric ABPM remain. Additional research is needed to validate more monitors in pediatric populations, to evaluate normative data across races and ethnicities and among smaller children, to assess outcomes from ABPM-based interventions, and to confirm whether or not ABPM is a cost-effective approach for long-term healthcare.